| Primary | Stroke Impact Scale (SIS) at 12-months Post-discharge | 59-item questionnaire to assess aspects of patient quality of life following stroke; includes 8 dimensions assessed on a 5-point Likert scale that are summed by domain. Scores range from 0-100, with higher scores indicating less difficulty. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 12 months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
| | | Title | Denominators | Categories |
|---|
| | | Title | Measurements |
|---|
| - OG00080.42± 21.28
- OG00183.85± 18.31
|
|
| |
| Primary | Modified Rankin Scale at 12 Months Post-stroke | The Modified Rankin Score (mRS) is a widely used scale to measure the degree of disability or dependence in daily activities of individuals who have suffered a stroke. Scores were categorized as 0-2 or >2. Overview of the Modified Rankin Scale
- 0: No symptoms at all
- 1: No significant disability; able to carry out all usual activities
- 2: Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance
- 3: Moderate disability; requiring some help, but able to walk unassisted
- 4: Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
- 5: Severe disability; bedridden, incontinent, and requiring constant nursing care
- 6: Dead
| Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12 months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Impact Scale (SIS) at 3-months Post-discharge | 59-item questionnaire to assess aspects of patient quality of life following stroke; includes 8 dimensions assessed on a 5-point Likert scale that are summed by domain. Scores range from 0-100, with higher scores indicating less difficulty. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | score on a scale | | 3-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Impact Scale (SIS) at 6-months Post-discharge | 59-item questionnaire to assess aspects of patient quality of life following stroke; includes 8 dimensions assessed on a 5-point Likert scale that are summed by domain. Scores range from 0-100, with higher scores indicating less difficulty. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 6-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Modified Rankin Scale (mRS) at 3-months Post-discharge | The Modified Rankin Score (mRS) is a widely used scale to measure the degree of disability or dependence in daily activities of individuals who have suffered a stroke. Scores were categorized as 0-2 or >2. Overview of the Modified Rankin Scale
- 0: No symptoms at all
- 1: No significant disability; able to carry out all usual activities
- 2: Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance
- 3: Moderate disability; requiring some help, but able to walk unassisted
- 4: Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
- 5: Severe disability; bedridden, incontinent, and requiring constant nursing care
- 6: Dead
| Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Modified Rankin Scale (mRS) at 6-months Post-discharge | The Modified Rankin Score (mRS) is a widely used scale to measure the degree of disability or dependence in daily activities of individuals who have suffered a stroke. Scores were categorized as 0-2 or >2. Overview of the Modified Rankin Scale
- 0: No symptoms at all
- 1: No significant disability; able to carry out all usual activities
- 2: Slight disability; unable to carry out all previous activities but able to look after own affairs without assistance
- 3: Moderate disability; requiring some help, but able to walk unassisted
- 4: Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
- 5: Severe disability; bedridden, incontinent, and requiring constant nursing care
- 6: Dead
| Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Blood Pressure Control (BP) at 3-months Post-discharge | To assess BP control through measurement of a seated patient using a blood pressure cuff; controlled BP is 120-130/80 or below for ischemic stroke patients and 140/80 or below for hemorrhagic stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors-Blood Pressure (BP) at 6-months Post-discharge | To assess BP control through measurement of a seated patient using a blood pressure cuff; controlled BP is 120-130/80 or below for ischemic stroke patients and 140/80 or below for hemorrhagic stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors-BP at 12-months Post-discharge | To assess BP control through measurement of a seated patient using a blood pressure cuff; controlled BP is 120-130/80 or below for ischemic stroke patients and 140/80 or below for hemorrhagic stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Cholesterol (LDL) at 3-months Post-discharge | To assess LDL/lipids control through a LDL or lipids blood draw (standard of care) for patients with elevated cholesterol at baseline (prior to hospital discharge); controlled LDL is less than/equal to 70 for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Cholesterol (LDL) at 6-months Post-discharge | To assess LDL/lipids control through a LDL or lipids blood draw (standard of care) for patients with elevated cholesterol at baseline (prior to hospital discharge); controlled LDL is less than/equal to 70 for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Cholesterol (LDL) at 12-months Post-discharge | To assess LDL/lipids control through a LDL or lipids blood draw (standard of care) for patients with elevated cholesterol at baseline (prior to hospital discharge); controlled LDL is less than/equal to 70 for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Blood Sugar (HgBA1c) at 3-months Post-discharge | To assess blood sugar control through a HgBA1c blood draw (standard of care) for patients with elevated blood sugar at baseline (prior to hospital discharge); controlled HgBA1c is less than/equal to 7% for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Blood Sugar (HgBA1c) at 6-months Post-discharge | To assess blood sugar control through a HgBA1c blood draw (standard of care) for patients with elevated blood sugar at baseline (prior to hospital discharge); controlled HgBA1c is less than/equal to 7% for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Blood Sugar (HgBA1c) at 12-months Post-discharge | To assess blood sugar control through a HgBA1c blood draw (standard of care) for patients with elevated blood sugar at baseline (prior to hospital discharge); controlled HgBA1c is less than/equal to 7% for stroke patients. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-discharge | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Body Mass Index (BMI) in kg/m^2 at 3-months Post-discharge | To assess weight status by measuring patients' weight and height and applying a formula; patients with normal weight have BMI kg/m*2=18.5-24.9 (BMI less than 18.5 kg/m^2 is underweight, and BMI 25.0 kg/m^2 or above is overweight (BMI=25.0-29.9 kg/m^2 ) or obese (BMI=30.0 kg/m^2 or above). | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | kg/m^2 | | 3-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Body Mass Index (BMI) in kg/m^2 at 6-months Post-discharge | To assess weight status by measuring patients' weight and height and applying a formula; patients with normal weight have BMI kg/m*2=18.5-24.9 (BMI less than 18.5 kg/m^2 is underweight, and BMI 25.0 kg/m^2 or above is overweight (BMI=25.0-29.9 kg/m^2) or obese (BMI=30.0 kg/m2 or above). | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | kg/m^2 | | 6-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Body Mass Index (BMI) in kg/m^2 at 12-months Post-discharge | To assess weight status by measuring patients' weight and height and applying a formula; patients with normal weight have BMI kg/m*2=18.5-24.9 (BMI less than 18.5 kg/m^2 is underweight, and BMI 25.0 kg/m^2 or above is overweight (BMI=25.0-29.9 kg/m^2) or obese (BMI=30.0 kg/m^2 or above). All measures are in kg/m*2 | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | kg/m^2 | | 12-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
|
| Secondary | Stroke Risk Factors - Diet at 3-months Post-discharge | Participants were asked one yes/no question to measure awareness of and adherence to the DASH (Dietary Approaches to Stop Hypertension) eating plan and the Mediterranean Diet. Total number of yes scores is provided where a yes score indicates better adherence to the dietary pattern and therefore in control and a no answer indicated poorer adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
|
| Secondary | Stroke Risk Factors - Diet at 6-months Post-discharge | Participants were asked one yes/no question to measure awareness of and adherence to the DASH (Dietary Approaches to Stop Hypertension) eating plan and the Mediterranean Diet. Total number of yes scores is provided where a yes score indicates better adherence to the dietary pattern and therefore in control and a no answer indicated poorer adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-stroke | | | | ID | Title | Description |
|---|
| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Stroke Risk Factors - Diet at 12-months Post-discharge | Participants were asked one yes/no question to measure awareness of and adherence to the DASH (Dietary Approaches to Stop Hypertension) eating plan and the Mediterranean Diet. Total number of yes scores is provided where a yes score indicates better adherence to the dietary pattern and therefore in control and a no answer indicated poorer adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Stroke Risk Factors - Smoking Status/Cessation at 3-months Post-discharge | Participants who ever smoked were asked one yes/no question "Do you smoke now?" to measure compliance with the smoking cessation recommendation. Total number of participants answering yes indicates adherence to the smoking cessation recommendation pattern and therefore in-control while a no answer indicates non-adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Stroke Risk Factors - Smoking Status/Cessation at 6-months Post-discharge | Participants who ever smoked were asked one yes/no question "Do you smoke now?" to measure compliance with the smoking cessation recommendation. Total number of participants answering yes indicates adherence to the smoking cessation recommendation pattern and therefore in-control while a no answer indicates non-adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Stroke Risk Factors - Smoking Status/Cessation at 12-months Post-discharge | Participants who ever smoked were asked one yes/no question "Do you smoke now?" to measure compliance with the smoking cessation recommendation. Total number of participants answering yes indicates adherence to the smoking cessation recommendation pattern and therefore in-control while a no answer indicates non-adherence and not in control. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Stroke Risk Factors - Exercise at 3-months Post-discharge | To assess self-reported adherence to American Stroke Association exercise guidelines (patients with stroke or transient ischemic attack (TIA) who are capable of at least moderate-intensity aerobic activity for a minimum of 10 minutes 4x per week, or vigorous intensity activity for a minimum of 20 minutes 2x per week is indicated) except as modified by the participants physician or physical therapist, Participants were asked one yes/no question to measure awareness of and adherence to the exercise recommendations Total number of participants with a yes score indicates adherence to the exercise recommendation pattern and therefore in-control while a no answer indicates non-adherence to the recommendation and not in control. . | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 3-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. Integrated Stroke Practice Unit: Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, and increase understanding and build positive behavior change for patients and caregivers. Primary and secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Stroke Risk Factors - Exercise at 6-months Post-discharge | To assess self-reported adherence to American Stroke Association exercise guidelines (patients with stroke or transient ischemic attack (TIA) who are capable of at least moderate-intensity aerobic activity for a minimum of 10 minutes 4x per week, or vigorous intensity activity for a minimum of 20 minutes 2x per week is indicated) except as modified by the participants physician or physical therapist, Participants were asked one yes/no question to measure awareness of and adherence to the exercise recommendations Total number of participants with a yes score indicates adherence to the exercise recommendation pattern and therefore in-control while a no answer indicates non-adherence to the recommendation and not in control. . | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 6-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Stroke Risk Factors - Exercise at 12-months Post-discharge | To assess self-reported adherence to American Stroke Association exercise guidelines (patients with stroke or transient ischemic attack (TIA) who are capable of at least moderate-intensity aerobic activity for a minimum of 10 minutes 4x per week, or vigorous intensity activity for a minimum of 20 minutes 2x per week is indicated) except as modified by the participants physician or physical therapist, Participants were asked one yes/no question to measure awareness of and adherence to the exercise recommendations Total number of participants with a yes score indicates adherence to the exercise recommendation pattern and therefore in-control while a no answer indicates non-adherence to the recommendation and not in control. . | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Count of Participants | | Participants | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Mortality at 12-months Post-discharge | Mortality following stroke will be assessed with family member, through study personnel, and/or using public sources. | | Posted | | Count of Participants | | Participants | | 12-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Rehospitalization | Rehospitalization following stroke will be assessed/confirmed with study personnel. | Analysis population reflects the number of participants with non-missing measurements. | Posted | | Count of Participants | | Participants | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Recurrence | Recurrence of stroke will be assessed/confirmed with study personnel. | Analysis population reflects the number of participants with non-missing measurements. | Posted | | Count of Participants | | Participants | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Time at Home | Time spent at home compared to institution assessed/confirmed with study personnel. Time at home is the proportion of time the participant spent at home out of their time at risk in this study (defined as being alive and with known status). The time at home is defined by subtracting time during hospitalization/rehabilitation/skilled nursing from the total time at risk and divided by total time at risk to get the proportion of time at home. | Analysis population reflects the number of participants with non-missing measurements. | Posted | | Mean | Standard Deviation | Proportion of Time | | 12-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Depression: Patient Health Questionnaire (PHQ-9) at 3-months Post-discharge | 9-item questionnaire to assess presence and/or severity of patient depression (includes an additional question to assess difficulty that doesn't impact scoring); scores range from 0-27, with 0=No depression, 1-4=Minimal depression, 5-9=Mild depression, 10-14=Moderate depression, 15-19=Moderately severe depression; and 20-27=Severe depression. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 3-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Depression: Patient Health Questionnaire (PHQ-9) at 6-months Post-discharge | Depression: Patient Health Questionnaire (PHQ-9) at 3-months post-discharge 9-item questionnaire to assess presence and/or severity of patient depression (includes an additional question to assess difficulty that doesn't impact scoring); scores range from 0-27, with 0=No depression, 1-4=Minimal depression, 5-9=Mild depression, 10-14=Moderate depression, 15-19=Moderately severe depression; and 20-27=Severe depression. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 6-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) |
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| Secondary | Depression: Patient Health Questionnaire (PHQ-9) at 12-months Post-discharge | 9-item questionnaire to assess presence and/or severity of patient depression (includes an additional question to assess difficulty that doesn't impact scoring); scores range from 0-27, with 0=No depression, 1-4=Minimal depression, 5-9=Mild depression, 10-14=Moderate depression, 15-19=Moderately severe depression; and 20-27=Severe depression. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 12-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | |
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| Secondary | Modified Caregiver Strain Index (mCSI) at 3-months Post-discharge | 13-item questionnaire to assess the level of strain in caregivers. Scores can range from 0-26, with higher scores indicating increased caregiver strain. Mean scores for each arm are provided and standard deviation of the mean. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 3-months post-stroke | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Modified Caregiver Strain Index (mCSI) at 6-months Post-discharge | 13-item questionnaire to assess the level of strain in caregivers, with higher scores indicating increased caregiver strain. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 6-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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| Secondary | Modified Caregiver Strain Index (mCSI) at 12-months Post-discharge | 13-item questionnaire to assess the level of strain in caregivers. Scores can range from 0-26, with higher scores indicating increased caregiver strain. Mean scores for each arm are provided and standard deviation of the mean. | Analysis population reflects the number of participants with non-missing measurements at this timepoint. | Posted | | Mean | Standard Deviation | Score | | 12-months post-discharge | | | | ID | Title | Description |
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| OG000 | Integrated Stroke Practice Unit (ISPU) | ISPU personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge. This will be supplemented by a more integrated model designed to increase coordination through team-based initiatives across the continuum of care for stroke - from acute and in-hospital care through 12 months post-discharge. Care teams will follow patients in their home or rehabilitation/skilled nursing facility monthly for 12 visits to assess recovery, manage risk factors, increase understanding, and build positive behavior change for patients and caregivers. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. | | OG001 | Comprehensive or Primary Stroke Center (CSC/PSC) | CSC/PSC personnel will continue with care provided under the Joint Commission-certified CSC/PSC design, including a 30-day clinic visit post-discharge, follow-up clinic visits as recommended by their outpatient provider, and other clinic visits initiated by the patient when issues arise. Primary outcomes will be assessed by phone at 3, 6, and 12 months; secondary outcomes will be assessed at 3, 6, and 12 months. |
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